State successes show health law can work

With all the waves of bad news about the Obamacare website and the canceled policies, it would be easy to conclude that nothing in this law will ever work — that it’s just too big and complicated and messy.

But that’s not the complete picture of the Affordable Care Act rollout. There are a few bright spots — just enough to suggest that, for all the early disasters, the law’s fate isn’t final yet.

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There are states that are running their own websites and enrolling a lot of people, way more than the amateur-hour federal website that serves most of the states. Medicaid enrollment, another part of the law, is going significantly better than the signups for private insurance — nearly 400,000 people were determined to be eligible in October.

And nationally, 1.5 million people applied for health coverage in October — suggesting that there’s a lot more potential interest than the 106,000 who got all the way through the federal and state Obamacare websites to select a private health plan.

So what do the bright spots tell us about the future of Obamacare? They certainly don’t tell us that the rollout is going well. But they do suggest that it’s not impossible for the law to work, health care experts say — because if it really were impossible, it wouldn’t be working anywhere.

In other words, the Obamacare rollout that we’ve all seen is not the story of a fatally flawed law. It’s a story of incompetence.

That’s probably not the talking point the White House is looking for. But it does suggest to health care experts that if the federal HealthCare.gov website ever does get its act together, there’s more potential for success in achieving the main goal — expanding health coverage to millions of Americans who couldn’t get it before — than the early numbers suggest.

“What we’re seeing is what’s possible under the Affordable Care Act,” said Alan Weil, executive director of the National Academy for State Health Policy. “The question is, how long will it be before we see those possibilities?”

In California, nearly 80,000 people had selected private health plans as of Nov. 19 — way beyond the 27,000 people who had picked private health plans in October through the federal website that serves 36 states. In New York, more than 76,000 had enrolled as of Nov. 24, including roughly 41,000 in private health plans and 35,000 in Medicaid. Enrollment has been also been going smoothly in Washington state and Connecticut — and even in Kentucky, Mitch McConnell’s home state, where Democratic Gov. Steve Beshear has been a vocal advocate of the law.

Only 14 states and the District of Columbia are running their own health insurance exchanges, so the law can get only so far with their efforts. But the lesson of these states’ early successes is that “where a state wants to make this work, it looks like they can,” said Peter Lee, executive director of Covered California, the state’s health insurance exchange.

Elaine Kamarck, a former adviser to Al Gore who worked on the “reinventing government” project in the Clinton administration, says that even at the national level, it shouldn’t have been impossible to build a functioning health care website. Despite all the federal government’s IT procurement problems, “the federal government does technology fairly well,” she said — from the advanced electronic surveillance capabilities of the National Security Agency to the rovers NASA sends to Mars.

The real lesson of the rollout, Kamarck said, is that the Department of Health and Human Services broke every rule for managing a big technological project well — and the successful states didn’t.

The three basic rules for launching a successful government tech project, Kamarck said, are to give one person the power and responsibility to supervise the entire project; build and test the technology repeatedly, since everyone knows websites crash; and create an environment where people feel free to give the boss bad news.

“Somehow, every rule of managing technology in government was broken with this website,” said Kamarck, who’s also the founding director of the Brookings Institution’s Center for Effective Public Management.

The bright spots don’t erase the other unpopular tradeoffs that Americans are discovering with the law — they’ll still be furious over canceled policies and whatever other nasty surprises are around the corner.

And there won’t be any end to the debate over whether the law has basic problems that can never be overcome. Lanhee Chen, Mitt Romney’s former policy director and now a research fellow at the Hoover Institution, says he believes the law is fundamentally flawed — even if a few states do well with it — because the conditions for success are too narrow to work across the country.

“There are going to be states where they won’t get help from state regulators. They’re not going to get that promotional push to get people enrolled,” said Chen. “The fundamental flaw in the law is that it requires people to be enrolled who don’t want to be enrolled.”